Current radiation therapy treatment planning is limited by suboptimal plan quality, inefficiency, and high costs. This perspective paper explores the complexity of treatment planning and introduces Human-Centric Intelligent Treatment Planning (HCITP), an AI-driven framework under human oversight, which integrates clinical guidelines, automates plan generation, and enables direct interactions with operators. We expect that HCITP will enhance efficiency, potentially reducing planning time to minutes, and will deliver personalized, high-quality plans. Challenges and potential solutions are discussed.

Radiation therapy treatment planning is an iterative, expertise-dependent process, and the growing burden of cancer cases has made reliance on manual planning increasingly unsustainable, underscoring the need for automation. In this study, we propose a workflow that leverages a large language model (LLM)-based agent to navigate inverse treatment planning for intensity-modulated radiation therapy (IMRT). The LLM agent was implemented to directly interact with a clinical treatment planning system (TPS) to iteratively extract intermediate plan states and propose new constraint values to guide inverse optimization. The agent's decision-making process is informed by current observations and previous optimization attempts and evaluations, allowing for dynamic strategy refinement. The planning process was performed in a zero-shot inference setting, where the LLM operated without prior exposure to manually generated treatment plans and was utilized without any fine-tuning or task-specific training. The LLM-generated plans were evaluated on twenty head-and-neck cancer cases against clinical manual plans, with key dosimetric endpoints analyzed and reported. The LLM-generated plans achieved comparable organ-at-risk (OAR) sparing relative to clinical plans while demonstrating improved hot spot control (Dmax: 106.5% vs. 108.8%) and superior conformity (conformity index: 1.18 vs. 1.39 for boost PTV; 1.82 vs. 1.88 for primary PTV). This study demonstrates the feasibility of a zero-shot, LLM-driven workflow for automated IMRT treatment planning in a commercial TPS. The proposed approach provides a generalizable and clinically applicable solution that could reduce planning variability and support broader adoption of AI-based planning strategies.

The reasoning and planning abilities of Large Language Models (LLMs) have been a frequent topic of discussion in recent years. Their ability to take unstructured planning problems as input has made LLMs' integration into AI planning an area of interest. Nevertheless, LLMs are still not reliable as planners, with the generated plans often containing mistaken or hallucinated actions. Existing benchmarking and evaluation methods investigate planning with LLMs, focusing primarily on success rate as a quality indicator in various planning tasks, such as validating plans or planning in relaxed conditions. In this paper, we approach planning with LLMs as a natural language processing (NLP) task, given that LLMs are NLP models themselves. We propose a recovery pipeline consisting of an NLP-based evaluation of the generated plans, along with three stages to recover the plans through NLP manipulation of the LLM-generated plans, and eventually complete the plan using a symbolic planner. This pipeline provides a holistic analysis of LLM capabilities in the context of AI task planning, enabling a broader understanding of the quality of invalid plans. Our findings reveal no clear evidence of underlying reasoning during plan generation, and that a pipeline comprising an NLP-based analysis of the plans, followed by a recovery mechanism, still falls short of the quality and reliability of classical planners. On average, only the first 2.65 actions of the plan are executable, with the average length of symbolically generated plans being 8.4 actions. The pipeline still improves action quality and increases the overall success rate from 21.9% to 27.5%.

Purpose: In high-dose-rate (HDR) prostate brachytherapy procedures, the pattern of needle placement solely relies on physician experience. We investigated the feasibility of using reinforcement learning (RL) to provide needle positions and dwell times based on patient anatomy during pre-planning stage. This approach would reduce procedure time and ensure consistent plan quality. Materials and Methods: We train a RL agent to adjust the position of one selected needle and all the dwell times on it to maximize a pre-defined reward function after observing the environment. After adjusting, the RL agent then moves on to the next needle, until all needles are adjusted. Multiple rounds are played by the agent until the maximum number of rounds is reached. Plan data from 11 prostate HDR boost patients (1 for training, and 10 for testing) treated in our clinic were included in this study. The dosimetric metrics and the number of used needles of RL plan were compared to those of the clinical results (ground truth). Results: On average, RL plans and clinical plans have very similar prostate coverage (Prostate V100) and Rectum D2cc (no statistical significance), while RL plans have less prostate hotspot (Prostate V150) and Urethra D20% plans with statistical significance. Moreover, RL plans use 2 less needles than clinical plan on average. Conclusion: We present the first study demonstrating the feasibility of using reinforcement learning to autonomously generate clinically practical HDR prostate brachytherapy plans. This RL-based method achieved equal or improved plan quality compared to conventional clinical approaches while requiring fewer needles. With minimal data requirements and strong generalizability, this approach has substantial potential to standardize brachytherapy planning, reduce clinical variability, and enhance patient outcomes.

Radiotherapy treatment planning is a complex and time-intensive process, often impacted by inter-planner variability and subjective decision-making. To address these challenges, we introduce Dose Optimization Language Agent (DOLA), an autonomous large language model (LLM)-based agent designed for optimizing radiotherapy treatment plans while rigorously protecting patient privacy. DOLA integrates the LLaMa3.1 LLM directly with a commercial treatment planning system, utilizing chain-of-thought prompting, retrieval-augmented generation (RAG), and reinforcement learning (RL). Operating entirely within secure local infrastructure, this agent eliminates external data sharing. We evaluated DOLA using a retrospective cohort of 18 prostate cancer patients prescribed 60 Gy in 20 fractions, comparing model sizes (8 billion vs. 70 billion parameters) and optimization strategies (No-RAG, RAG, and RAG+RL) over 10 planning iterations. The 70B model demonstrated significantly improved performance, achieving approximately 16.4% higher final scores than the 8B model. The RAG approach outperformed the No-RAG baseline by 19.8%, and incorporating RL accelerated convergence, highlighting the synergy of retrieval-based memory and reinforcement learning. Optimal temperature hyperparameter analysis identified 0.4 as providing the best balance between exploration and exploitation. This proof of concept study represents the first successful deployment of locally hosted LLM agents for autonomous optimization of treatment plans within a commercial radiotherapy planning system. By extending human-machine interaction through interpretable natural language reasoning, DOLA offers a scalable and privacy-conscious framework, with significant potential for clinical implementation and workflow improvement.

Since the explosion in popularity of ChatGPT, large language models (LLMs) have continued to impact our everyday lives. Equipped with external tools that are designed for a specific purpose (e.g., for flight booking or an alarm clock), LLM agents exercise an increasing capability to assist humans in their daily work. Although LLM agents have shown a promising blueprint as daily assistants, there is a limited understanding of how they can provide daily assistance based on planning and sequential decision making capabilities. We draw inspiration from recent work that has highlighted the value of 'LLM-modulo' setups in conjunction with humans-in-the-loop for planning tasks. We conducted an empirical study (N = 248) of LLM agents as daily assistants in six commonly occurring tasks with different levels of risk typically associated with them (e.g., flight ticket booking and credit card payments). To ensure user agency and control over the LLM agent, we adopted LLM agents in a plan-then-execute manner, wherein the agents conducted step-wise planning and step-by-step execution in a simulation environment. We analyzed how user involvement at each stage affects their trust and collaborative team performance. Our findings demonstrate that LLM agents can be a double-edged sword -- (1) they can work well when a high-quality plan and necessary user involvement in execution are available, and (2) users can easily mistrust the LLM agents with plans that seem plausible. We synthesized key insights for using LLM agents as daily assistants to calibrate user trust and achieve better overall task outcomes. Our work has important implications for the future design of daily assistants and human-AI collaboration with LLM agents.

Radiotherapy (RT) planning is complex, subjective, and time-intensive. Advances in artificial intelligence (AI) promise to improve its precision, efficiency, and consistency, but progress is often limited by the scarcity of large, standardized datasets. To address this, we introduce the Automated Iterative RT Planning (AIRTP) system, a scalable solution for generating high-quality treatment plans. This scalable solution is designed to generate substantial volumes of consistently high-quality treatment plans, overcoming a key obstacle in the advancement of AI-driven RT planning. Our AIRTP pipeline adheres to clinical guidelines and automates essential steps, including organ-at-risk (OAR) contouring, helper structure creation, beam setup, optimization, and plan quality improvement, using AI integrated with RT planning software like Eclipse of Varian. Furthermore, a novel approach for determining optimization parameters to reproduce 3D dose distributions, i.e. a method to convert dose predictions to deliverable treatment plans constrained by machine limitations. A comparative analysis of plan quality reveals that our automated pipeline produces treatment plans of quality comparable to those generated manually, which traditionally require several hours of labor per plan. Committed to public research, the first data release of our AIRTP pipeline includes nine cohorts covering head-and-neck and lung cancer sites to support an AAPM 2025 challenge. This data set features more than 10 times the number of plans compared to the largest existing well-curated public data set to our best knowledge. Repo:{https://github.com/RiqiangGao/GDP-HMM_AAPMChallenge}

Diverse, top-k, and top-quality planning are concerned with the generation of sets of solutions to sequential decision problems. Previously this area has been the domain of classical planners that require a symbolic model of the problem instance. This paper proposes a novel alternative approach that uses Monte Carlo Tree Search (MCTS), enabling application to problems for which only a black-box simulation model is available. We present a procedure for extracting bounded sets of plans from pre-generated search trees in best-first order, and a metric for evaluating the relative quality of paths through a search tree. We demonstrate this approach on a path-planning problem with hidden information, and suggest adaptations to the MCTS algorithm to increase the diversity of generated plans. Our results show that our method can generate diverse and high-quality plan sets in domains where classical planners are not applicable.

With the advancement of treatment modalities in radiation therapy for cancer patients, outcomes have improved, but at the cost of increased treatment plan complexity and planning time. The accurate prediction of dose distributions would alleviate this issue by guiding clinical plan optimization to save time and maintain high quality plans. We have modified a convolutional deep network model, U-net (originally designed for segmentation purposes), for predicting dose from patient image contours. We show that, as an example, we are able to accurately predict the dose of intensity-modulated radiation therapy (IMRT) for prostate cancer patients, where the average dice similarity coefficient is 0.91 when comparing the predicted vs. true isodose volumes between 0% and 100% of the prescription dose. The average value of the absolute differences in [max, mean] dose is found to be under 5% of the prescription dose, specifically for each structure is [1.80%, 1.03%](PTV), [1.94%, 4.22%](Bladder), [1.80%, 0.48%](Body), [3.87%, 1.79%](L Femoral Head), [5.07%, 2.55%](R Femoral Head), and [1.26%, 1.62%](Rectum) of the prescription dose. We thus managed to map a desired radiation dose distribution from a patient's PTV and OAR contours. As an additional advantage, relatively little data was used in the techniques and models described in this paper.

In the field of domain-independent planning, several powerful planners implementing different techniques have been developed. However, no one of these systems outperforms all others in every known benchmark domain. In this work, we propose a multi-planner approach that automatically configures a portfolio of planning techniques for each given domain. The configuration process for a given domain uses a set of training instances to: (i) compute and analyze some alternative sets of macro-actions for each planner in the portfolio identifying a (possibly empty) useful set, (ii) select a cluster of planners, each one with the identified useful set of macro-actions, that is expected to perform best, and (iii) derive some additional information for configuring the execution scheduling of the selected planners at planning time. The resulting planning system, called PbP (Portfolio- based Planner), has two variants focusing on speed and plan quality. Different versions of PbP entered and won the learning track of the sixth and seventh International Planning Competitions. In this paper, we experimentally analyze PbP considering planning speed and plan quality in depth. We provide a collection of results that help to understand PbPs behavior, and demonstrate the effectiveness of our approach to configuring a portfolio of planners with macro-actions.